On harelip and cleft palate

by William Rose

Many surgeons still retain the plan first introduced and figured by Ambrose Paré[74] of uniting the edges by means of harelip pins and figure-of-8 sutures; but this has been largely superseded by the use of silver wire and intermediate fine sutures.

Good results undoubtedly followed the old plan of treatment, and it had the advantage in pre-anæsthetic days of being more rapidly accomplished. But success could not be depended on for the following reasons: it was more difficult to adjust the edges with exactness, and the muscular movements of the lip were liable to cause them to slip, and being hidden by the coils of superjacent suture the displacement was undetected until the removal of the pins. Moreover the track of the pins, especially if they were retained beyond the fourth day, was liable to become the seat of suppuration, and unsightly cicatrices resulted. In some instances the pins cut their way out of the lip, leading to still more evident cicatricial deformity, and the liability to septic infection of the wound was of course much greater. At the same time I have no desire to detract from the one great and acknowledged advantage of pin-transfixion and figure-of-8 suture, viz. the steadying and accurate approximation of the deeper parts, when efficiently inserted; but I maintain that the same advantages can be secured by the use of silver wire as detailed below.

When harelip pins are used, the method of introduction is as follows:—The first pin should be inserted close to the muco-cutaneous margin, and about one centimetre from the edge of the right side of the lip, and its point should emerge on the deep aspect of the raw surface close to the mucous membrane. It should then be passed on through the opposite side of the lip, entering at an exactly corresponding point on the raw surface, and passing out through the skin of the left side at the same distance from the edge as on the other. One or two more pins should be similarly passed at equal distances through the other portions of the cleft. Moderately thick unwaxed silk is now used as a figure-of-8 suture, whilst during this the assistant presses the cheeks, and holds the lip in situ. The parts should not be dragged together by this means, but merely retained in the position to which they have been easily brought by the pressure of the assistant’s fingers, as a result of the previous undercutting. A separate silken thread is advisable for each pin. The pins are now cut short by wire-nippers, and collodion painted over all.

The plan I now adopt, in common with many others, of suturing the prepared lip is as follows:—Purified silver wire of No. 27 gauge is carefully threaded on special wire needles. I introduce two or three sutures by entering the needle at rather more than half a centimetre from the margin, and bringing out the point on the raw surface close to the mucous membrane as with the pins, taking care to pass the needle in on the opposite side at an exactly corresponding point. The three situations I select for these sutures are, one at the root of the nose or upper part of the cleft; one a little above the muco-cutaneous junction; and the third, if necessary, between the other two. In very young infants and simple cases, only two wires are needed.

Having passed the wires and tested the accuracy of their position, the ends are left long and unfastened lying on the cheeks, whilst the fine catgut sutures are being adjusted. By means of small semicircular needles, about two centimetres in diameter, held in a needle-holder, these sutures are inserted, as near to the margin of the cleft as is possible, consistent with their holding. The first two should be placed one at the muco-cutaneous junction, and the other at the nostril aperture as high as is necessary in order to bring about the approximation of the ala nasi to the median line, and thus secure the diminution in the size of the opening, and a symmetrical disposition of the features.[75]

As many other fine sutures as are necessary are now inserted between these two. In regard to the mucous membrane of the lip and the formation of the prolabium, care must be taken that the exact edges are stitched together, as they are very liable to curl in. It will be found of great assistance if the catgut of the first suture in the mucous membrane be not cut short, but used as a holder to lift the lip during the passage of the next stitch, which will fulfil the same office for the succeeding one, and so on, until, in this way, the mucous membrane can be thoroughly everted, and fine sutures carried through the edges on the buccal aspect. The effect of this is most satisfactory in maintaining exact coaptation of this part of the lip, which is so liable to be displaced when the child is fed or cries, permitting the entrance of food or saliva which will interfere with the progress of union. The wire stitches (sutures of relaxation) are now fastened, and in doing so there is no necessity to tighten them unduly; experience alone can teach the requisite amount of tension. This completed, all traces of blood are removed from the face, and the sutured lip carefully cleansed with a purified sponge dipped in boracic acid lotion.

A collodion dressing is then applied in the following manner: a piece of antiseptic gauze folded double is cut butterfly fashion, so that one wing is fixed upon each cheek, and the uniting portion, just the width of the lip, passes over the wound. Collodion is carried close up to, but not over, the wound itself, which is merely covered by the bridge of gauze. During the adjustment of the dressing, the assistant should hold the cheeks forward, and this position must be maintained until the collodion is firm. The contractile nature of this dressing is especially useful in limiting to some extent the movements of the cheek.

In former days the use of Hainsby’s truss or cheek compressor was much in vogue, with the object of relaxing, as far as possible, all tension on the flaps; but the apparatus has now been discarded by most surgeons. The pressure of the spring was occasionally so severe as to cause sloughing of the cheek (as I have seen in one or two cases many years ago); or else there was a great liability for the pads to slip out of position during any sudden movement of the child’s head, leading to injurious pressure on or near the wound itself. In fact, if the truss was acting efficiently, pain and irritation to the child resulted; if it was comfortable, it was generally useless.

One of the principal points to be attended to in the after-treatment is to instruct the nurse to depress the lower lip with the index finger for some hours after the child has recovered from the anæsthetic, and to repeat it occasionally until it becomes accustomed to the diminished oral aperture; otherwise the efforts to draw air through the mouth (now closed for the first time) will tend very considerably to disturb the wounded surfaces.[76]

Spoon food must be so administered as to allow it to touch the upper lip as little as possible. The arms should be fixed to the side to prevent them touching the face. In young infants constant attention day and night is necessary, for they are very liable to roll the head from side to side, and so bring the sutured lip in contact with the bedclothes, which causes pain and makes the child cry, a most undesirable occurrence. The state of the bowels should be attended to, and if constipation exist, a small dose of grey powder with magnesia may be advisable. The silver wire sutures should usually be taken out on the fourth day; the catgut stitches may remain a week, or some of them until absorbed, the collodion dressing being re-applied when necessary, and maintained for a few days after the catgut has disappeared or been removed. Occasionally saliva and milk soak into and under the gauze, producing a moist condition of the skin around the freshly united wound, which may lead to eczema. The gauze should then be left off, and the parts gently washed with warm boracic lotion and dusted over with a mixture of equal parts of powdered oxide of zinc and starch. In mild cases without alveolar complication the child may be put to the breast on the fifth or sixth day, if the condition of the wound is satisfactory. But in the severe forms, or where the union is weak and threatens to give way, most careful spoon-feeding and general watchfulness must be continued. In spite, however, of every precaution, the depression of the nostril will sometimes persist or reappear as cicatricial contraction takes place, and a slight notch in the lip cannot be always prevented.